Learning and recommendations from Significant Event Analyses of Bowel Cancer cases

Problem

Bowel cancer is the second leading cause of cancer-related mortality in the UK. Early diagnosis of bowel cancer provides opportunities for curative treatment and improved survival. Significant Event Analysis (SEA) is a well-established quality improvement activity and method for learning from new cancer diagnoses. The existing literature has primarily focused on learning from SEAs of lung cancer cases and emergency admissions. This project aimed to provide additional insights into the diagnostic processes for bowel cancer and to develop the use of multi-site SEA as an educational tool.

Approach

Seventy-five General Practices across Pennine Lancashire were invited to undertake SEAs of one or more bowel cancer cases from the preceding three years as part of an incentivised scheme. Anonymised data were collected on a standardised form. Practices provided learning outcomes and recommendations for the practice, hospital and local Clinical Commissioning Groups (CCGs). 51/75 (68%) practices have submitted data so far. Data collection and thematic analysis is currently ongoing and the completed results will be presented at the meeting.

Findings

The preliminary analysis of results has highlighted an increased awareness of “red flag” bowel cancer presentations; particularly rectal bleeding and iron deficiency anaemia. Caution should be exercised due to diagnostic overshadowing from haemorrhoids and presumed intentional weight loss. Rectal examination was considered an essential component to clinical assessment. Clinicians were encouraged to consider a lower threshold for 2-week suspected cancer referrals and the use of faecal immunochemical tests; particularly for younger patients or patients presenting with atypical symptoms. The diagnostic limitations of computed tomography scans were recognised, however, direct access scanning was advocated when endoscopic investigations were deemed inappropriate. Strategies for reducing missed diagnoses included continuity of care, pro-active patient follow-up and safety-netting. Both General Practices and CCGs were recommended to improve the promotion of bowel cancer screening and implementation of standardised systems for the follow-up of non-responders. Conversely, clinicians should not be falsely reassured by previously negative screening results. Commissioners were recommended to continue support of multi-site SEA projects; oversee effective communication between primary and secondary care; improve flexibility with suspected cancer referrals, and to address deficits in patient education on early symptom recognition.

Consequences

Thematic analysis of multi-site SEAs provides an opportunity for collaborative learning from new cancer cases. These findings confirm and provide additional insights to the existing literature on bowel cancer from a primary care perspective. The broad range of cases from multi-site SEA should be utilised across Primary Care Networks for peer-peer learning and identification of Network-wide improvements in cancer pathways. Further research is required regarding the use of SEA for improving and sustaining cancer outcomes.